4 Background July 2008 Increasing diabetic i population Intensive resource use Population at high risk for co-morbidities Not meeting EPRP performance measures No access to real-time data: Who are our diabetic patients? Who is at risk for poor outcomes? Multi-disciplinary team chartered by PVAMC Chief of Staff to develop registry 4

18 Patient Report Card Goal set by your PCP For education and outreach to patients includes for all DM measures: date and values of last test goal for most people for test interpretation of last results date test next due backsideisa is a glossary of terms explaining each test, why needed, how done. 18

20 Example Registry Function: Patient Lab Letters Three month pilot started t 2/23/09 Centralized 1-2 click production Letters to patients missing A1c or LDL with appointment w/in 2 weeks Last available lab results, how to get labs done, and appointment reminder Used policy order to allow lab staff to enter order Approximately 1000 letters sent during pilot 20

23 How is the registry used in practice? Patient triage and proactive disease management: We identify vets with a1c s over 8, to make sure that appropriate follow-up is being made by either via PCP phone/sma/1:1 appts, nursing phone/drop in appts, endo, or clinical pharmacy consults. I make a custom list of the patients that are scheduled for each of my diabetes clinics so that I can review their reports, see the trends, and order the labs or appointments, perform any exams that need to be done. The RN scans for high BP and A1c. She will have pt s come into the RN HTN group visit for rechecks and discuss needed f/u with pcp. Improve annual monitoring i of relevant tests/exams: t The RN and LPN scan the registry for tests (labs, Eye, foot exam, etc) that are overdue and schedule f/u. The facilitator pulls up a monthly patient list according to birth date and schedules those patients t into our RN lead annual DM group visit. it Patient education and engagement: I give each veteran a copy of their report and the team report card that gives the meds, etc, and explain what the report shows, what each section means, and I encourage them to be actively involved, i.e. if the lab test is due and they haven t heard from their provider, that they should call and be proactive to get what needs to be done.done. 23

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